Endometriosis Presenting as a Rare Cause of Intestinal Perforation: A Case Report With Literature Review

A 39‐year‐old woman with a history of endometriosis was referred to the emergency department due to severe abdominal pain, accompanied by vomiting and nausea. The abdominal pain had started 3 days before her admission. The patient didn't have a drug history or underlying disease. The patient's vital signs were T  = 37.9, HR = 140, BP = 90/50. Upon examination, there was noticeable distension, generalized tenderness, and rebound tenderness. Routine laboratory tests showed leukocytosis. A chest radiograph indicated pneumoperitoneum beneath the diaphragm, and Upright and supine abdominal radiographs showed intestinal obstruction (Figure  1 ). Our assessment indicated peritonitis caused by an intestinal obstruction, and the patient was readied for exploratory laparotomy. During the procedure, a mass was found next to a perforation in the ileum. The mass and the perforated segment of the ileum were resected, and the intestine was reconnected (Figure  2 ). Chest X‐ray and upright and supine abdominal X‐ray before surgery. Findings during laparotomy. Microscopic examination of the resected intestinal wall showed evidence of congestion, focal transmural hemorrhage, and areas of necrosis. Additionally, focal endometrial glands and stroma, accompanied by fibrotic stroma, were observed. One lymph node exhibited reactive changes, and there was also peri‐intestinal infiltration of neutrophils. The final diagnosis was small bowel perforation due to endometriosis. The patient was hospitalized for 3 days and did not have a fever during her stay. On the second day, she began a liquid diet, and bowel movements resumed on the third day. She was discharged with a prescription. Eight days later, she returned for suture removal. Upon evaluation, her overall condition was stable, and her nutritional intake was adequate.

Farnood Forouhar: data curation, methodology, supervision, writing – review and editing. Narges Mesbah: data curation, writing – original draft. Sina Esmailpour: data curation, writing – original draft. Peyman Bastani: methodology, writing – original draft. Mostafa Salimi: data curation, writing – original draft, writing – review and editing, supervision.

A 39‐year‐old woman with a history of endometriosis experienced severe abdominal pain, vomiting, and nausea. Urgent surgery revealed intestinal perforation. A mass was found and resected. Pathology confirmed intestinal endometriosis as the cause. Despite being a common gynecological disease, the exact pathogenesis of endometriosis remains unclear. Due to this vague pathogenesis, finding a proper classification system to approach this disease is yet problematic [ 8 ]. Though there is no gold standard staging system for endometriosis, the “ENZIAN” classification appears reasonable for surgical planning. A key advantage of the ENZIAN classification is that it offers detailed descriptions of the retroperitoneal structures; However, its accuracy is compromised if deep invasive lesions are not fully resected or if imaging is done without surgery [ 9 ]. According to a study, magnetic resonance imaging (MRI) facilitates preoperative surgical planning and uses the ENZIAN score to forecast the degree of disease before surgery [ 10 ]. A review suggested that transvaginal ultrasonography (TVS) should be the primary diagnostic tool for women with rectosigmoid endometriosis. The extensive use of TVS can accelerate the diagnostic process and facilitate treatment for intestinal endometriosis. The conclusion was promising for improving patient care [ 11 ]. The report's single‐case nature limits the generalizability of the findings. More research is needed to understand the pathophysiology of bowel involvement in endometriosis and to develop definitive management guidelines. Although rare, endometriosis involving the bowel can mimic other gastrointestinal disorders with nonspecific symptoms [ 6 , 12 ]. This case's progression to perforation stresses the potential severity of endometriosis‐related complications. Previous studies have documented similar cases requiring surgical treatment [ 13 ]. Clinically, this case emphasizes the importance of considering endometriosis in women with acute abdominal symptoms, especially those with known endometriosis. It also highlights the need for a solid diagnostic method and prompt surgical evaluation in cases of suspected bowel perforation. In conclusion, this case exemplifies the severe gastrointestinal complications that can arise from endometriosis, stressing the importance of vigilance and timely surgical management. To compare and review other similar patients, we conducted a short literature review of case reports on this topic, published from 2024 onward (detailed in Table  1 ), highlighting the range of clinical manifestations associated with endometriosis, which can present with significant severity. Future research should aim to uncover the mechanisms behind bowel perforation in endometriosis and optimize treatment protocols. Literature review.

The patient's written consent was obtained for the publication of this case report.

Endometriosis is a health issue characterized by endometrial tissue and stroma‐like lesions outside the uterus, potentially affecting various organs in the body. This condition causes a long‐lasting inflammatory reaction, frequently leading to significant suffering and health complications [ 1 ]. While some women with endometriosis experience debilitating symptoms, including dysmenorrhea and infertility, others may remain asymptomatic, underscoring the heterogeneous nature of this disease [ 2 ]. Although classified as a benign condition, endometriosis can profoundly impact reproductive health, particularly in women of reproductive age [ 3 ]. The exact prevalence of endometriosis is not well established; however, estimates indicate that it impacts as many as 15% of women of reproductive age and approximately 70% of those experiencing chronic pelvic pain [ 4 ]. The pathogenesis of endometriosis is predominantly linked to menstruating women, and the retrograde menstruation theory, popularized by Sampson, postulates that menstrual debris can traverse the fallopian tubes, implant onto peritoneal surfaces, and subsequently infiltrate adjacent tissues [ 5 ]. Gastrointestinal endometriosis can involve both the large and small intestines, and the diagnostic gold standard for this manifestation includes diagnostic laparoscopy accompanied by biopsy [ 6 ]. Symptoms associated with gastrointestinal endometriosis are heterogeneous, encompassing abdominal pain, bloating, diarrhea, and, in some cases, an absence of symptoms altogether [ 7 ]. As exemplified in clinical reports, gastrointestinal endometriosis may present with more severe manifestations such as abdominal pain, nausea, vomiting, and bowel perforation, which may necessitate surgical intervention. Given the symptomatic overlap with other gastrointestinal disorders, notably Crohn's disease, clinicians must consider small bowel endometriosis within the differential diagnosis framework [ 6 ]. This report underscores the need to recognize gastrointestinal manifestations of endometriosis, which can lead to severe complications such as bowel perforation. We are presenting this case to help increase awareness and promote timely diagnosis, which can improve patient outcomes.

The authors declare no conflicts of interest.